Bioethics. Группа авторов

of people than ever before (Singer 2004). There are historical reasons why third parties’ interventions in procreation are looked at with suspicion, and the shadow of eugenics seems to extend over any discussion regarding reproductive technologies and their governance (Paul 1992). Despite these worries, the regulation of new reproductive technologies will be influenced by governments’ policies, which in turn will reflect the interests of society and societal views on emerging reproductive technologies. Regarding the governance of genome editing technologies and their potential use in the context of assisted reproduction, the interests of society might play a role in two main ways: the first is whether genome editing is ethically acceptable for a large segment of society (Kitcher 2001), and second, related, is whether existing alternatives warrant the introduction of a new practice and the clinical research necessary to safely implement it. Almost every new technology introduced or discussed for potential introduction in reproduction seems to stir controversies. The recent debates on genome editing (Camporesi and Cavaliere 2016), mitochondrial replacement techniques (Appleby 2015) and ‘older’ debates on PGD (Scott 2006) are just a few instances of these controversies. However, once certain uses are constrained and lines drawn (for instance between therapeutic and enhancing uses), these technologies have been approved and, at least in certain countries, accepted by large swaths of the population. Thus, even if genome editing will be met with controversies and will encounter resistance, it does not prima facie translate into the need for banning any research involving it. On the contrary, this should translate into support for a democratic and deliberative approach to the governance of technological innovation (Jasanoff et al. 2015) and into the respecting of competing moral views on these issues (Cavaliere 2017).

      Societal interests and the costs of introducing genome editing in the context of assisted reproduction

At this point, there is, however, there is one last thing to consider, which concerns the aforementioned interests of society and how they should and could play a role in the ethical assessment of introducing genome editing in the context of assisted reproduction. While it is true that genome editing could open up new reproductive possibilities for certain couples (i.e. enhance reproductive autonomy) and provide heritable benefits to their future offspring (i.e. considerations regarding the welfare of future child), these benefits ought to be balanced against the costs of introducing a new reproductive technology. These costs include the investment of public resources, considering both the scarcity of such resources and the existence of available alternatives. Emanuel et al. (2000) argue that for clinical research to be ethical, among other requirements, it needs to have social value, namely it should be directed at “a diagnostic and therapeutic intervention that could lead to improvements in health and well‐being” (Emanuel et al. 2000). Being of social value is an ethical requirement for clinical research to go forward precisely because it operates in a context of scarce resources. From this it follows that if the social value of a technology is limited, then the investment of public resources for the development and implementation of such technology may be unethical (Rulli 2016b). The proposed clinical research (in this case that needed in order to implement genome editing as an alternative to PGD) needs to be evaluated on two levels: absolute and relative. The absolute level is settled once the proposed research is expected to bring about improvements to health and well‐being. The relative level, however, needs more: the proposed research (and the improvements to health and well‐being thereof) needs to be compared both with other potential uses of those scarce resources and with existing alternatives to bring about similar improvements to health and well‐being. Two of the criteria that are often employed to assess whether to invest resources in certain clinical research and whether it will bring about significant improvements to health and well‐being are the severity of the condition and the number of individuals that it affects (Rulli 2016b). If we consider these two criteria, the benefits of the introduction of genome editing as a new reproductive option are arguably minor and thus may not warrant the investment of public resources. The number of cases for which PGD is not an option, as mentioned in the first section, is limited. In addition, considering the importance of taking into account future children’s welfare, the unresolved questions concerning safety seem to indicate that health improvements may not be so significant. An obvious critique to this is the following: clinical research is aimed at improving techniques in order to achieve significant benefits for future children. This is certainly correct and we would not enjoy the benefits of many technologies and drugs if it was not for clinical research. But again: resources are limited and not all research can be publicly funded.

      Returning to the relative level to evaluate clinical research, it is important to consider that improvements in the health and well‐being of future children can also be achieved by looking at alternative solutions, for instance third party reproduction or adoption. For those limited number of parents for whom PGD is not an option, the choice is not between genome editing and a sick child. The choice is much wider than that. This does not mean that the choice of adopting or relying on third party reproduction comes without a cost, or that prospective parents’ wishes should be neglected. It only means that there are other interests at stake and that there are other strategies than developing new technologies to tackle health needs.

      These considerations do not lead to the conclusion that public interest (in the form of a prudent use of resources) should be prioritised over prospective parents’ reproductive autonomy and future offspring’s welfare. On the contrary, the received view, namely the view that considers the interests of these two groups as more morally relevant than those of society, ought to be taken as the default position. But this position should not prevent us from seeking alternatives. Perfecting existing technologies such as PGD, and possibly widening the criteria of access to adoption or third party reproduction, would be a less costly and possibly quicker strategy to grant future children’s welfare while at the same time respecting prospective parents’ wishes. Making existing technologies and practices available via broader state funding schemes would allow their use by larger swaths of the population.

Conclusions: Context Matters

      In this article, I have analysed the moral case for introducing genome editing as an alternative to PGD. I have presented the reasons in favour and the two main arguments against this possibility, namely safety and germline modifications. After presenting some of the available data on the safety of CRISPR, I have argued that concerns with germline modifications do not represent a compelling argument against the introduction of genome editing into the clinic. I have then turned to arguments in favour of genome editing and concluded that there seems to be a prima facie case in favour of starting clinical research with CRISPR. In the last section, I have focused on the moral reasons that are normally taken into account in debates on reproductive technologies, namely the welfare of future children, the reproductive autonomy of the parents and the interests of society. I have showed that a closer look at genome editing in light of these moral reasons seems to generate some additional reasons for caution in accepting genome editing as a new reproductive option. These reasons may entail shifting from funding new resources, such as CRISPR, and advocating for its introduction in the name of values such as reproductive autonomy and the welfare of future children, to focusing on widening the criteria of access to existing options and possibly re‐thinking resource allocation and state funding of assisted reproduction. This paper does not attempt to provide decisive arguments in favour of or against the introduction of CRISPR as a new reproductive option. As many have argued, it may be too soon to have a conclusive assessment of this possibility, if only for the dearth of empirical data regarding its safety and feasibility. Rather, this paper offers a basis to begin a discussion on the ethics of introducing genome editing as an alternative to PGD and stresses the need to consider that scientific research does not happen in a vacuum where the soundest theoretical argument wins. Rather, it happens in a context where resources are limited, where genetic parenthood is an important value cherished by many, and where technical solutions are often given preference over other strategies.

References

      1 Appleby, John B. 2015. The ethical challenges of the clinical introduction of mitochondrial replacement techniques. Medicine, Health Care and Philosophy